CARE HOME ADULTS 18-65
Alness Lodge 50 Alness Road Whalley Range Manchester M16 8HW Lead Inspector
Steve O`Connor Unannounced Inspection 13th June 2006 12:00p Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Alness Lodge Address 50 Alness Road Whalley Range Manchester M16 8HW 0161 226 4313 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mohan Ramsumair Mrs Peggy Ramsumair Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: Alness Lodge is a residential care home providing 24-hour personal care and accommodation for 10 persons with mental health problems. The home is situated in the Whalley Range area of Manchester, close to local amenities and public transport routes. It is sited on a residential street and was originally a purpose built home for older people. It has a small car park to the front and a garden at the rear. Bedroom accommodation is on the ground and first floors. All the bedrooms are single with hand washbasins. The home is unable to offer a service to people with restricted mobility due to the layout and lack of access around the building. Communal space is provided on the ground floor with a dining room that leads to a large lounge and through to a conservatory with access to the garden. The kitchen and laundry facilities are also situated on the ground floor. The philosophy of the home focuses on maintaining independence and rehabilitation. The manager stated that it is their aim to build on peoples skills and enable people to participate in the day-to-day running of the home. Information about the home can be found in the Statement of Purpose and Service User Guide and is provided to prospective residents. Inspection reports can be made available through direct request to the home. From April 2006 the fees for the home are approximately £650 a week. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission since the last inspection report of November 2005. This information includes the previous requirements from that inspection report, a pre-inspection questionnaire, completed by the home and submitted to the Commission on the 2nd May 2006 and an unannounced site visit on the 13th June 2006. During the site visit time was spent talking to people who live at the home, staff on duty and the manager. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. What the service does well:
Developing a staff team that has the skills and knowledge to support people is an important responsibility of the home. They recognise this and have been very active in working with a local authority project to help smaller care homes to get the training that staff need. In addition, time has been spent with staff to further develop their skills and knowledge of understanding and supporting people with mental health problems. This commitment to improving the quality of the service and staff team has lead to the home being awarded the Investors In People. This is a nationally recognised award that commits the home to improving the quality of its service through a skilled workforce. The home continues to offer a safe, secure and comfortable environment and support to people who would not be able to cope on their own living in the community. The home showed that they were continuing to do well in this area through the support they offered people who need reassurance and support with their worries and concerns. Staff were observed supporting a person with eating their meal. They made sure that they sat close to them and talked to them throughout. Later they encouraged the person to help them with some domestic tasks again talking to them in a positive and respectful way and thanking the person for the help they were giving. All the people spoken to said that they were happy with the home and the support they received from staff and management. Comments from people and from questionnaires they had completed included positive comments of the staff team and the manager.
Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 6 Staff showed that they had a good understanding of the needs of the people they support and were clear about their roles in supporting people to stay as independent as possible and to make the home a safe place for them. The importance of communication and working with people was stressed and how being able to give comfort and reassurance reduces the impact of people’s mental health. The relationships between people and staff appeared friendly and relaxed with time spent together talking, joking, singing or joining in activities. What has improved since the last inspection? What they could do better:
Vulnerable people sometimes place themselves, and others, at risk because of their behaviour, which may be due to their mental health problems. When it is known that there is a certain behaviour that may cause some problems for the person then it is the home’s responsibility to make sure that they are familiar with what happens and put in place ways that can either prevent or reduce the risk from happening. Staff working with that person will need guidance on how they going to respond and work with them to make sure that they receive the support they need. The home has identified and responded to a number of known risks that people may face but must make sure that they have acted on all those risks that they know about. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 7 The home supports people with long-term mental health problems. For many people part of the help they receive to remain healthy is in taking the right medication at the right time. To do this the home has a medication administration system that should record accurately in sufficient detail all aspects of a person’s medication. The home’s medication recording and checks are not accurate enough to make sure that people are taking their medication safely. For the last two inspection reports they have been asked to make sure there are clear written guidance for staff to be give medication that is prescribed ‘as required’ (PRN). They have still not done this. There were mistakes in recording medication given, delivered and they had run out or nearly run out of three peoples’ medication before new supplies were delivered. The home must make sure that it has the right checks and monitoring in place so that these mistakes are picked up and put right quickly. The home helps and supports people to manage their monies, finances and valuables. To make sure that people and the home are safe and protected the home needs to keep very good accurate and detailed records of all spending and money given to people and that peoples’ possessions in their keeping are secure. The home needs to look at how it does this to make sure that everyone is protected. The previous inspection report asked the home to look at how it was going to find out from people who live at and are connected to the home what they feel about the quality of the service. The home has started to look at this by asking people to complete a questionnaire about different aspects of the service. The home is also looking into new ways of how it records information about the service and the people it supports and this includes looking at the quality of the home. This action should continue to help the home find out what it is doing well and where it may need to improve things for the people living at the home. It is the home’s responsibility to make sure that the staff it employs are safe to work with vulnerable people. This includes making sure staff have no criminal convictions that could affect the people they work with and that they have not been placed on the Protection of Vulnerable Adult List of people who have been banned from working with vulnerable adults. This is checked through getting a Criminal Records Bureau (CRB) check. All the staff have these checks but some of them were done over three years ago. The recommended guidance from the CRB is that a check is made every three years and the home is recommended to follow this guidance. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by
Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples’ needs and goals had been identified and generally had the opportunity to experience the home before deciding to live there. EVIDENCE: The purchasing authorities had provided the home with a Care Programme Approach (CPA) assessment and care plan for each person coming to live at the home. Pre-admission assessments from other relevant health and behavioural assessments were also available from healthcare providers. In addition, the home undertook it’s own in-house assessment. From this an individual care plan was developed. The pre-admission assessment from the purchasing authorities was of a variable quality. One person’s information was very detailed and in-depth and had been carried out just prior to the person coming to stay at the home. The other assessment seen was dated from October 2004 and did not include any recent assessment material. It is recommended that the home ensure that the pre-assessment information provided by purchasing authorities is up-to-date and current. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home identifies and reflects peoples’ changing needs and support. People are supported to take decisions and choices and risks to peoples’ wellbeing are generally recognised and acted upon. However, not all risk situations have been clearly recognised. EVIDENCE: The purchasing authorities had provided the home with a care plan for each person setting out, in general terms, the support they needed. These care plans were reviewed at least on an annual basis through the Care Programme Approach (CPA) multi-disciplinary review process. Although the home does not formally review peoples’ support/care plan changes in needs and goals are reflected in updated care plans. From the pre-admission assessment information and knowledge gained by the home from the person they develop a care and risk assessment plan for each individual. The care plan includes a range of personal, social and emotional needs and goals and how to support the person. Risk assessments also identify
Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 12 potential hazards relating to peoples’ environment and behaviour and include such contributing factors such as the use of alcohol and emotional wellbeing. A person’s assessment information had identified a known behavioural risk. However, although the manager was aware of the issues involved and had discussed these with the staff and other relevant agencies, there was no record or guidance for staff in how to respond to the behaviour. If a persons’ actions/behaviour is identified as a risk the home must develop a clear risk assessment and support guidance to minimise that risk. Due to people’s mental health and associated problems there were agreed restrictions placed on people such as use of alcohol, cigarettes and access to money. A relevant risk assessment and agreement had been developed with the person. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were offered opportunities to take part in valued and meaningful activities both within the home and the community. The home’s daily routine was relaxed and informal and people are supported to maintain relationships with their families. Meals are based on peoples’ preferences and offer choice and nutritional balance. EVIDENCE: A number of people still have a structured programme of events and activities that they participate in that are provided by the local mental health service such as drop-ins, a women’s centre and other specialist leisure and education services. Several people are independent in the community and will use the local community facilities when they want to. In the home people have access to television, videos, music, reading, craft activities and games. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 14 Several people spoken to were very reluctant to go outside into the community, even with staff support. The issue of some people not having the motivation or choosing not to take part in the opportunities offered by the home was discussed with the manager. It is recommended that the home record the opportunities offered to people to take part in leisure and social activities even if they refuse. This shows that the home is continually trying to offer people meaningful activities. The routine of the home was relaxed and informal with no strict times set for activities such as personal care or visitors. People would take part in household activities according to their abilities and the state of their health. Family and friends were encouraged to visit and maintain contact and relationships with people. People said that they enjoyed the meals and had a choice of the things that they liked. Peoples’ nutritional needs were known and people were encouraged to follow as healthy a diet as possible. Mealtimes were usually a communal event and a chance for people to catch up with each other. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported to maintain their personal, health and mental care needs. However, the medication administration system does not fully protect people. EVIDENCE: A number of people were independent in maintaining their own personal care whilst others still required prompting and encouragement. Where a person did require additional support this was recorded in the person’s care plan. Any risks associated with moving and handling had been identified. The home supported people to attend regular appointments with general and specialist healthcare providers. People’s mental health was monitored on an ongoing basis where this was required. The medication administration system was assessed and it was found that staff had missed signing for some doses of peoples’ medication. The Medication Administration Record (MAR) sheet had included several records of the code ‘O’ for ‘Other’ but there was no written explanation for why that dose of medication had been missed. It was found that the record for deliveries of medication had not included the actual amount of Lactulose. It was also found that three peoples’ prescribed Lactulose had either run out or was almost
Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 16 empty before a new supply had arrived. The home could give no reasonable explanation for this happening. The home’s monitoring systems in relation to the medication administration system had not identified these issues. The medication administration recording systems must be maintained accurately at all times. The systems must be regularly monitored and audited to ensure they are being maintained. Previous inspection reports had highlighted that several people were prescribed with medication to be given ‘as required’ (PRN). The home had been required to develop clear administering guidance for staff to follow for each of the medication. This had still not been addressed despite the home being provided with information from the inspector and so the requirement was reiterated again. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People feel that they can express their concerns and worries and the home have some of the systems in place to respond to concerns of peoples’ safety. However, the home does not have in place all the systems and practices to ensure that people are fully protected. EVIDENCE: The home’s Complaint Policy set out the process and the timescales involved in making a formal complaint. The contact details of the Commission for Social Care Inspection were included. The policy was available to people and was seen attached to the notice board in the dining room. People spoken to were able to explain that if they had any concerns or worries then they were able to speak to the staff and manager to help resolve them. The home follows a clear Adult Protection policy and procedure that had been read by the staff team. The staff team had participated in Adult Protection training events. The home is working with the relevant professional, purchasing and legal authorities to ensure that peoples’ financial affairs are being managed in a safe and secure way. The home supports people to manage their monies and spending. All transactions are recorded and regular audits are undertaken to ensure that balances are correct. It is recommended that the home keep separate receipts for all people’s spending to ensure the auditing and monitoring systems are accurate.
Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 18 The home must review its procedures for managing peoples’ finances and valuables to ensure that all necessary safety precautions are being taken. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, well-maintained and homely home. There are systems in place to maintain the cleanliness and hygiene of the home. EVIDENCE: The home was clean, well maintained and decorated and had a homely atmosphere. People spent time in the communal areas or in their own bedrooms. There was a no smoking policy in the house and people can only smoke in the garden. Staff carried out the majority of the daily cleaning of the home and support and encourages people to undertake domestic tasks. The kitchen contained clear instructions on the use of colour coded food preparation boards and the boards were seen. The laundry room contained a domestic washing machine and a tumble dryer that was sufficient to meet people’s needs. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a staff team who have the skills and competence to meet their needs. The home has the systems in place to ensure that staff that work with vulnerable people are safe to do so. EVIDENCE: The home put forward staff to undertake the vocational qualification NVQ Level 2. Currently, three of the staff team had gained NVQ Level 2 or above and several staff were being registered to begin the course. Staff were observed working and interacting with people in a positive and competent way. The staff team consists of the manager and eight support workers covering the day and night shifts. The manager has a flexible work schedule to be able to cover the times when people need supporting to attend health appointments and organised social/leisure events. There are three staff working during the day, two in the evening and two staff available during the night. The home was carrying one vacancy. Staff files contained all the required documentation and information relating to their application and employment. Criminal Record Bureau (CRB) disclosure certificates are sought prior to staff starting work. The manager confirmed that her and several members of the staff team had CRB certificates that were over three years old. There were no systems in place to find out whether staff had
Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 21 any criminal convictions or were placed on the POVA List since the last CRB check. It is recommended that the home develop a monitoring system to ensure that people disclose any criminal convictions and that CRB Disclosure certificates are renewed according to CRB guidance. The home had introduced a new induction programme based on the Skills for Care Induction Modules that come into effect in September 2006. Staff had access to a range of in-house and other training organisations to provide the Induction and Mandatory training. Each member of staff have their individual training log and plan and a system for assessing competence. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from an experienced and qualified manager and has the systems and practices in place to maintain the health and safety of those living and working in the home. The systems for seeking peoples’ views in terms of quality assurance have not yet been fully implemented. EVIDENCE: The manager is also the joint owner of the home. They have the management experience, skills and qualifications required to manage the home to meet its stated aims and objectives. The manager shows a commitment to maintaining peoples’ mental health and wellbeing and to support peoples’ needs with a stable and competent staff team. The previous inspection report highlighted the need for the home to develop its own quality assurance system based on the views of people who use and have contact with the service. The manager was in the process of introducing a new management recording system for the home that included a quality assurance
Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 23 process. This included supporting people to complete a questionnaire about their experience of the home. As the process had not yet been fully implemented the requirement was reiterated and progress will be assess over the course of the next inspection. The home is maintaining regular health and safety checks in respect to fire, water and food storage temperatures. Gas, electric and fire equipment is being serviced on an annual basis. The home had the relevant documentation and information regarding COSHH and RIDDOR and a policy on the reporting of incidents. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13 Requirement Timescale for action 30/07/06 2. YA20 13 3 YA20 13 All identified risks must be followed by a risk assessment and guidance on how to minimise those risks. Clear and detailed guidance 01/07/06 must be developed for each service user prescribed with PRN medication. (The timescale of the 15/07/05 and 30/11/05 were not met). Evidence of the guidance must be provided to the CSCI within the timescale stated. The following aspects of the 01/07/06 medication administration system must be addressed. 1. All doses of medication administered must be recorded on the MAR chart. 2. The coding system for recording why a person has missed medication must be clear and include an explanation as to why that medication was missed. 3. Records of all medication delivered must include the quantity of the medication. 4. Systems must be put in place to ensure that peoples’ medication does
DS0000021600.V298727.R01.S.doc Version 5.2 Alness Lodge Page 26 4 YA23 13 5 YA39 24 not run out before the next delivery is due. 5. An auditing and monitoring system must be developed and introduced to ensure that the administration systems are correct. The home must review its 01/07/06 procedures for managing peoples’ finances and valuables to ensure that all necessary safety precautions are being taken. A quality assurance system must 30/08/06 be implemented based on the requirements of standard 39. (The timescale of 01/02/06 was not met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA2 YA23 YA34 Good Practice Recommendations It is recommended that the home ensure that the preassessment information provided by purchasing authorities is up-to-date and current. It is recommended that the home keep separate receipts for all people’s spending to ensure the auditing and monitoring systems are accurate. It is recommended that the home develop a monitoring system to ensure that people disclose any criminal convictions and that CRB Disclosure certificates are renewed according to CRB guidance. Alness Lodge DS0000021600.V298727.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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